Concussion will affect later gave disability. Timely and quality assistance to victims

ITU in CRANIO-BRAIN INJURIES

Definition

Traumatic brain injury (TBI) - mechanical damage to the skull and intracranial contents (substances of the brain, membranes, blood vessels, cranial nerves), manifested by focal, cerebral and mixed symptoms, due to primary structural and functional changes, and later - indirect (mediated) pathophysiological and pathomorphological processes.
Epidemiology
TBI is one of the most common types of injuries. Their frequency is 1.8-5.4 cases per 1000 population and, according to WHO, increases by an average of 2% per year. TBI account for 30-50% in the overall structure of injuries. Among the causes of TBI in Russia, household factors prevail (50-78%), transport (mainly road) injuries are in second place (10-30%), and industrial ones are in third (12-15%) (Lichterman J1. B., 1995). The number of victims with TBI due to military operations is increasing. Compared to Great Patriotic War during local armed conflicts of recent times, the number of injuries to the skull and spine has almost doubled. Overall, about 1,200,000 people suffer brain damage every year, resulting in huge economic losses.
The social significance of TBI is great. It is due to: 1) the predominant defeat of persons under the age of 50, the most active in social, labor and military terms; 2) common cause loss of working time and economic damage (about 2.5% in cases and 6% in days in relation to all diseases of the nervous system with temporary disability); 3) as a cause of death and disability in people of young and younger middle age, TBI is ahead of cardiovascular and oncological diseases; 4) complete recovery after TBI occurs only in 30-50% of the victims;
5) frequency and severity of disability. Every year, of the total number of people recognized as disabled for the first time due to injuries of all localizations, more than 35% are people with consequences of TBI(Boeva ​​E. M., 1991). Among the causes of disability in neurological patients, injuries occupy the 2nd-3rd place (about 12%). The number of severely disabled people is large (40-60% of those examined are defined as II and I groups of disability); 6) disability due to TBI is very long-term (often determined indefinitely), and in 30-35% of cases it is established in the long-term period 'many years after the injury.
Classification
I. Periods during traumatic illness brain:
1. Acute (2-10 weeks depending on the clinical form of TBI).
2. Intermediate. With mild TBI - up to 2 months, with moderate - up to 4 months, with severe - up to 6 months.
3. Remote: with clinical recovery - up to 2 years, with a progressive course, the duration is not limited.
II. Classification of the acute period of TBI (Konovalov A. N. et al., 1986; approved by the Ministry of Health).
1. a) closed: there are no violations of the integrity of the integument of the head, or there are soft tissue wounds without damage to the aponeurosis. Fractures of the skull bones that are not accompanied by injury to the adjacent soft tissues and aponeurosis are classified as closed TBI;
b) open: fractures of the bones of the cranial vault, accompanied by injury to the adjacent soft tissues, fractures of the base of the skull, accompanied by bleeding or liquorrhea (from the nose or ear), as well as soft tissue wounds with damage to the aponeurosis. With the integrity of a solid meninges open TBI is classified as non-penetrating, and if its integrity is violated, it is referred to as penetrating. Both can be complicated (meningitis, meningoencephalitis, brain abscess), and when penetrating, there may be a foreign body in the cranial cavity.
2. Clinical forms of closed TBI:
a) concussion;
b) mild contusion of the brain;
c) brain injury medium degree;
d) severe brain contusion;
e) compression of the brain against the background of his contusion;
e) compression of the brain without concomitant contusion.
3. According to the degree of severity, there are: a) mild TBI - concussion and contusion of the brain of a mild degree; b) moderate TBI - moderate brain contusion; c) severe TBI - severe contusion and compression.
4. TBI can be:
a) isolated (no extracranial injuries);
b) combined (at the same time there are damage to the bones of the skeleton and (or) internal organs);
c) combined (simultaneously thermal, radiation, chemical and other injuries);
d) primary;
e) secondary, caused by immediately preceding cerebral dysfunction (stroke, epileptic seizure, vestibular crisis, acute hemodynamic disorder of various origins, etc.);
e) received for the first time and repeated.
III. Classification of the consequences of TBI(according to Likhterman L. B., 1994; with changes).
1. Mostly non-progressive: local or diffuse atrophy of the brain, meningeal scars, subarachnoid and intracerebral cysts, aneurysms; bone defects of the skull, intracranial foreign bodies, lesions of the cranial nerves, etc.
2. Mostly progressive: hydrocephalus, basal liquorrhea, subdural hygroma, chronic subdural (epidural) hematoma, carotid-cavernous anastomosis, porencephaly, cerebral arachnoiditis, epilepsy, parkinsonism; autonomic and vestibular dysfunctions, arterial hypertension, cerebrovascular disorders, mental disorders, etc.).
Leading neurological post-traumatic syndromes:
1) neurological deficit; 2) mental dysfunctions; 3) autonomic dysregulation; 4) epileptic; 5) vestibular;
6) liquor-dynamic.
Often there is a combination of different effects. Progressive and non-progressive variants of consequences are largely determined by the type (open, closed) and severity of TBI.
Pathogenesis
IN last years many issues of the pathogenesis of TBI have been studied, which made it possible to supplement the concept of L. I. Smirnov about traumatic brain disease (Likhterman L. B., Konovalov A. N. et al., 1990-1996; Shogam I. I. et al., 1989- 1990; Mikhailenko A. A. et al., 1993, etc.). In many respects, this became possible due to the use of modern methods of brain imaging (CT, MRI, PET), immunological, biochemical, neurohumoral studies.
1- The problem of diagnosis, pathogenesis and treatment of Diffuse axonal brain damage, which is more common in children and young people in the acute period of trauma, has been developed. New data on the formation and dynamics of post-traumatic cerebral edema (based on CT and MRI data) have been obtained.
2. The study of some neurochemical processes in the acute period of injury (lipid peroxidation and the state of the antioxidant system) has been developed. It was shown that an increase in the content of malonic aldehyde in the blood and cerebrospinal fluid corresponds to the severity of the injury and correlates with the amount of lactate.
3. Immunological studies have shown that the immunodeficiency state plays an important role in the pathogenesis of the acute period and the consequences of closed TBI. Autoimmune processes play an important role in the pathogenesis of diffuse post-traumatic arachnoiditis of the brain.
4. Neuropeptides, biogenic amines-mediators and other neurohumoral factors of cerebrospinal fluid and blood, which are important for the pathogenesis and sanogenesis of TBI, are being actively studied. The data obtained are used in determining the severity of the injury, the localization and volume of the contusion focus, and the treatment of patients (G. A. Vartanyan, B. I. Klementyev, 1991; A. Yu. Makarov, V. G. Pomnikov, 1982, 1995).
Considerable attention is paid to vascular complications of the late period of closed TBI (vegetative dystonia, arterial hypertension, early atherosclerosis) caused by damage to the limbic-reticular structures of the brain.
6. Gerontological aspects of the problem of acute and late periods of TBI, pathogenetic and clinical features of vascular pathology that develops in elderly patients against the background of the consequences of trauma are specially considered (Makarov A. Yu., Pomnikov V. G., 1994, 1996).
Clinic and diagnostic criteria
1. In the acute period of TBI.
1) Concussion occurs in 70-80% of victims with TBI. It is a set of transient disorders of cerebral functions: short-term loss of consciousness (from several seconds to several minutes); headache, dizziness, nausea, vomiting, oligokinesia, pallor of the skin (especially the face), tachycardia or bradycardia, arterial hyper- or hypotension. There may be retro-, con- and anterograde amnesia less than 30 minutes, difficulty concentrating, weakening of memory processes, horizontal nystagmus, weakness of convergence. CSF pressure and its composition, CT of the brain without pathology, but sometimes MRI can detect changes in the white matter of the hemispheres.
2) Brain contusion - a more severe form of head injury, characterized by focal neurological symptoms, varying degrees of severity of cerebral, and in severe cases, stem disorders. Often, brain contusion is accompanied by subarachnoid hemorrhage, in 35% of cases - fractures of the bones of the vault and base of the skull.
By CT or post-mortem examination, morphological changes in the brain substance are revealed.
N a) mild brain contusion (in 10-15% of victims) occurs with loss of consciousness (from several minutes to an hour), mild or moderate cerebral symptoms, pyramidal insufficiency in the form of anisoreflexia, rapidly passing mono- or hemiparesis, possible dysfunction cranial nerves. Focal neurological symptoms regress after 2-3 weeks, antero- and retrograde amnesia is short-lived. CSF pressure in most patients is increased, less often - normal or low. In the case of subarachnoid hemorrhage, erythrocytes are found. CT in half of the observations reveals a zone of reduced density of the brain tissue, the average values ​​of which are close to those of cerebral edema;
b) brain contusion of moderate degree (in 8-10% of victims) is characterized by loss of consciousness lasting from several tens of minutes to several hours. Mental disorders in the form of a decrease in criticism of one's condition, disorientation in time, the environment, impaired attention, etc. are observed within 7-12 days after the clarification of consciousness. Sometimes there is short-term psychomotor agitation. Against the background of cerebral disorders, focal, and often shell symptoms are detected, which persist from 2 to 3-5 weeks. Focal epileptic seizures may occur. In the cerebrospinal fluid - a macroscopically noticeable admixture of blood. The protein content can reach 0.8 g/l. The pressure of the cerebrospinal fluid is different, but more often it is increased. Fractures of the bones of the vault and base of the skull occur in 62% of cases. On CT in 84% of cases focal changes in the form of high-density small inclusions that are not compactly located in the zone of low density, or a moderate homogeneous increase in density;
c) severe brain contusion occurs in 5-7% of cases. There are four clinical forms: extrapyramidal, diencephalic, mesencephalic and mesencephalo-bulbar. The extrapyramidal form is observed with lesions predominantly of the hemispheres big brain and subcortical formations. In the clinical picture - hyperkinesis, increased muscle tone, often replaced by hypotension, sometimes motor excitation, often signs of damage to the diencephalon and midbrain (mildly). In patients who are in coma, recovery of consciousness occurs slowly, through phases of apallic syndrome and akinetic mutism.
In the diencephalic form, there are clear signs of damage to the hypothalamus: against the background of prolonged (from several hours to several weeks) stupor or coma, severe hyperthermia, rapid, undulating or aperiodic breathing, increased blood pressure, tachycardia, neurodystrophic changes in the skin and internal organs. Revealed in varying degrees pronounced focal hemispheric and stem symptoms"
Mesencephalic and mesencephalo-bulbar forms are clinically manifested in addition to impaired consciousness up to coma of cerebral and focal hemispheric symptoms, a clear lesion of the midbrain or predominantly lower divisions trunk (pons and medulla oblongata).
Liquor with severe brain bruises may contain a significant admixture of blood, its sanitation occurs on the 2-3rd week after the injury. In most patients, fractures of the bones of the vault and base of the skull are detected. On CT - focal lesions of the brain in the form of a zone of inhomogeneous or homogeneous increase in density. Focal symptoms regress slowly, pronounced consequences in the form of motor and mental disorders.
The most severe is the so-called diffuse axonal injury of the brain, in which CT or autopsy reveals many limited hemorrhages in the semioval center of both hemispheres, in the stem and periventricular structures, the corpus callosum against the background diffuse increase brain volume due to swelling or edema. The latter causes an increase in intracranial hypertension with dislocation of the brain and infringement of stem structures at the tentorial or occipital levels. Typical changes in muscle tone (hormetonia, diffuse hypotension), hemi- and tetraparesis, distinct vegetative disorders, hyperthermia. A transition from a prolonged coma to a persistent or transient vegetative state is characteristic, manifested by the opening of the eyes (spontaneously or in response to irritation). Its duration is from several days to several months, after which distinct extrapyramidal, atactic, mental disorders are revealed. The prognosis is usually unfavorable - death or profound disability.
3) Compression of the brain (in 3-5% of victims) is characterized by a life-threatening increase in one or another period of time after the injury or immediately after it, cerebral and focal, in particular stem, symptoms. Depending on the background on which traumatic compression of the brain develops, the light gap may be unfolded, erased or absent. Among the causes of compression in the first place are intracranial hematomas(epidural, intracerebral, subdural), which are well identified by CT. Diagnosis of chronic subdural hematomas, which are clinically manifested later, is especially difficult.
3 weeks, often several months after injury in elderly and senile patients. They can be after minor injuries, in the absence of skull fractures, often accompanied by mental disorders (delirium, disorientation), mild focal symptoms, while the hypertensive syndrome is absent or mild. This is followed by depressed fractures of the bones of the skull, foci of crushing of the brain with perifocal edema, subdural hygromas, pneumocephalus. Syndrome is described as a special form prolonged compression head, characterized by combined damage to the soft integument of the head, skull and brain (occurs in victims of landslides, earthquakes and other disasters). It proceeds hard - a long and deep disturbance of consciousness, not corresponding to the severity of head injury, high temperature, severe cerebral and somatic disorders.
2. In the remote period of TBI.
1) Direct consequences. Their features: a) occur immediately after the injury or in the intermediate period; b) in the long term they regress to varying degrees, stabilize (reach one or another level of compensation) or progress; c) the nature of the leading syndrome largely depends on the severity of TBI (Mikhailenko A. A. et al., 1993): with a mild injury, the syndrome predominates vegetative dystonia; with moderate - syndrome of liquorodynamic disorders and epileptic; with severe - cerebral-focal.
Main Syndromes:
- syndrome of vegetative dystonia (in 60% of cases). It is observed mainly in those who have had a mild closed head injury, much more often in the first months and years after the injury. Clinical manifestations are typical for autonomic dystonia (see section 12.2). Vegetative disorders can be aggravated or transformed under the influence of additional factors: physical and emotional overload, somatic diseases, intoxication (often alcohol), etc.;
- psychopathological disorders (in most cases combined with vegetative disorders) are observed in 80-90% of patients. Can be in any period of injury. In the long-term period, they are a reflection of those present in the acute period, but sometimes they appear for the first time, provoked by the influence of additional factors ( alcohol intoxication, infections, etc.). They are diverse: asthenic (in those who have undergone mild and moderate trauma it is the main one in 40% of cases), astheno-neurotic, hypochondriacal, psychopathic, pathological development personality, dementia;
- vestibular syndrome (in 30-50% of patients who had a closed TBI). Possible in any period of injury. Associated with hearing loss. Vestibular disorders (often paroxysmal) are manifested by dizziness, imbalance, nausea, and vomiting. They are provoked by sudden movements of the torso, head, travel by transport, meteorological factors, etc. They can be caused both by primary trauma to the brain stem and by secondary disorders of blood and liquor circulation leading to dysfunction of cochleo-vestibular structures. Differ in resistance, auditory disturbances quite often progress;
- liquorodynamic disorders (in 30-50% of patients) are more often manifested by intracranial hypertension. Less often (usually in the acute and intermediate periods) hypotension occurs. Gi-
pertensive syndrome, as a rule, is a complex symptom complex: symptoms of increased CSF pressure, vegetative, vestibular, often psychopathological, etc. Against the background of constant headache of varying severity, periodically (with different frequency) hypertensive crises occur (for details, see Chapter 6). The diagnosis takes into account the possibility of normotensive hydrocephalus, usually developing in the late period of injury as a result of diffuse atrophy of the brain and clinically manifested by progressive dementia, walking dysfunction, urinary incontinence;
- post-traumatic epilepsy. It occurs in 15-25% of cases, more often in those who have had a moderate injury. There are grounds to distinguish three variants of epilepsy caused by TBI (Makarov A. Yu., Sadykov E. A., 1997): 1) consequences of TBI with epileptic seizures, distinct changes in CT, MRI. basis clinical picture, severity and prognosis determine other consequences of brain injury; 2) actually post-traumatic epilepsy. Against the organic background of long-term consequences of TBI (in the presence of morphological changes on CT, MRI), the leading role belongs to epileptic seizures, there is a certain originality of the clinical picture, features of personality changes; 3) consequences closed injury brain (usually mild) in the absence of a morphological component (according to CT and MRI) or an organic background of seizures. Trauma is a provoking factor in the development of epilepsy with a very likely hereditary predisposition.
In 60-70% of patients clinically and according to EEG data, a focal component is detected in the structure of the seizure. The most typical are primary and secondary generalized convulsive seizures, in particular Jacksonian, less often psychomotor. Epilepsy forms earlier after a severe bruise (about a year), later (after
2 years or more) - after a concussion. dynamically (via
5 years after injury), the number of patients with seizures increases, reaching a maximum by the age of 20. In the long term after the injury, seizures become less frequent, transform into lighter ones. However, they can reappear after repeated TBI, intoxication, in an extreme situation, against the background of cerebral vascular pathology, developed post-traumatic arachnoiditis;
- narcoleptic syndrome of traumatic etiology is observed in 14% of cases. It usually manifests itself against the background of other consequences of TBI, caused by dysfunction of the structures of the limbic-reticular complex (see Chapter 13);
- neuroendocrine-metabolic form hypothalamic syndrome clinically formed in the remote period of closed TBI. Often there are associated neurotrophic disorders. The main neuroendocrine syndromes and the course of the disease are described in Sec. 12.4;
- cerebrofocal syndromes are much more common in patients with moderate and severe trauma, and in the latter they are leading in 60% of cases. Apart from
brain, open TBI is a common cause of focal lesions. The severity of focal disorders in the late period of injury is much less than in the acute one. Regression in most syndromes occurs most actively in the first months and first year after TBI, however, compensation and adaptation to the defect are possible in the future. At the same time, the rate and degree of recovery of functions clearly depend on the nature of neurological symptoms. For example, pyramidal motor and coordination disorders, aphasia, apraxia usually regress faster and more completely than visual (eg, hemianopsia), neuropathy auditory nerve. Extrapyramidal syndromes - parkinsonism (sometimes hemiparkinsonism), chorea, athetosis, etc. - are rare (in 1-2% of cases), progress slowly, their severity does not reach the degree observed with a different etiology of the disease (see Chapter 10) . However, the severity of motor deficit, as well as other direct consequences of TBI, may increase against the background of the associated cerebral vascular pathology.
Focal neurological disorders, as a rule, are combined with other consequences of TBI: open injury more often with epileptic seizures, with closed - with vegetative dystonia, vestibulopathy, liquorodynamic, psychopathological disorders.
2) Indirect (mediated) consequences. Their features:
a) occur, as a rule, after a closed TBI, more often mild, moderate; b) are formed many months, years after the acute period of injury; c) the pathogenesis is based on endocrine-metabolic, autoimmune, angiodystonic disorders caused by pathology of the limbic-reticular structures of the brain; d) progredient course with periods of exacerbations, relative remissions.
Main Syndromes:
- vascular complications that appear in the late period of closed TBI in 80% of patients, mostly untreated and poorly treated (Makarov A. Yu., Pomnikov V. G., 1996);
- symptomatic arterial hypertension. It develops in 18-24% of persons who have had a closed TBI, and in 70% of them 5-20 years after the injury. The main criteria for diagnosis and distinction from hypertension: occurrence after TBI, usually against the background of other consequences of trauma; relatively low numbers, high lability and asymmetry of blood pressure (reaches 20-40 mm) over the years; lack of parallelism between the duration of the increase in blood pressure and the state of the fundus; hypertrophy of the left ventricle of the heart develops late and not always; no renal syndrome. Staging during the course of the disease is not observed, a long-term course is characteristic with remissions and exacerbations under the influence of adverse factors (stressful conditions infections, alcohol abuse).
complications: PNMK (primarily crises), ischemic stroke (usually in combination with cerebral atherosclerosis);
- early atherosclerosis of cerebral vessels. Contribute to angiodystonia, lipid disorders and other types of metabolism endocrinopathy caused by TBI. It occurs more often than in the healthy population, is usually diagnosed after many years of compensation for a traumatic disease at the age of 30-40 years. It is often combined with atherosclerosis of the aorta, peripheral and coronary arteries, symptomatic arterial hypertension. Leads to the progression of psychopathological disorders (include traumatic and vascular features). Complications: transient ischemia, strokes, dementia;
- post-traumatic cerebral arachnoiditis (diagnosed in 7-10% of people who have had a closed TBI). The autoimmune nature of the process determines the duration of the light interval after injury. Active (actual) arachnoiditis is clinically more often manifested in terms from 6 months to 1.5-2 years. The severity of TBI can vary. Questions of the clinic, diagnosis, in particular, the differences between active arachnoiditis and residual adhesive atrophic and cystic changes after a brain contusion and an open TBI, are set out in Chap. 6.
3. Features of the consequences of open TBI:
a) skull defect due to injury and (or) subsequent surgery, foreign bodies inside the skull. A defect is considered significant when its size, as measured on the craniogram, exceeds 3 * 1 cm (area 3 sq. cm) or at a smaller area if there is a brain pulsation;
b) there is a high risk of infection and the occurrence of purulent complications: meningitis, meningoencephalitis (often recurrent), brain abscess;
c) the possibility of post-traumatic basal (nasal, ear) liquorrhea, usually due to a fracture of the bones of the skull base. Long-term liquorrhea (up to 3 years or more) in 60-70% of cases is the cause of recurrent purulent meningitis;
d) there are complications caused by cicatricial changes in the meninges (Jackson's epileptic seizures, occlusive hydrocephalus, etc.);
e) predominance (in contrast to closed TBI) of cerebrofocal syndromes over vegetative-vascular, neuroendocrine, neurosomatic, etc., caused by dysfunction of structures of the limbic-reticular complex;
f) limitation of the adhesive membrane process by the wound zone, in contrast to diffuse cerebral arachnoiditis, characteristic of closed TBI;
g) maximum clinical manifestations in the acute period of injury, satisfactory (in uncomplicated cases) regression of focal symptoms in the intermediate and long-term periods.
4. Data from additional studies:
- cerebrospinal fluid examination: pressure (determination of the nature of the violation of cerebrospinal fluid dynamics in the acute and late periods of injury); the composition of the cerebrospinal fluid: erythrocytes - objectification of brain injury, subarachnoid hemorrhage; neutral
Aile pleocytosis is a complication of purulent meningitis; the increase in protein content is the greatest in the acute period of severe malnutrition (up to 3 g/l and above) with a subsequent decrease; lactate - An increase to 3-5 mmol / l or more indicates the severity of the injury and a poor prognosis; products of lipid peroxidation (an increase in the content of malonaldehyde correlates with the severity of injury); physiologically active substances(neuropeptides, biogenic amines-mediators, enzymatic
u) judgment on the severity of the consequences of TBI, predominantly
chocalization of the lesion (the most distinct changes in the pathology of the limbic-reticular structures of the brain);
echo-EG - an approximate judgment about the presence of hydrocephalus, displacement of the median structures of the brain due to meningeal and intracerebral hematoma;
- CT, MRI are very informative methods of brain imaging, allowing: to objectify the state of the ventricular system, subarachnoid space, brain substance, to clarify the clinical form of TBI, in particular, the severity of the bruise, the presence of intracerebral and meningeal hematoma, hygroma; trace the dynamics of the process of restoration of functions in the intermediate period of TBI; obtain information about the nature and localization of brain lesions (cysts, cicatricial-atrophic changes) in the long-term period of TBI; determine indications for surgical treatment; clarify the clinical prognosis, the degree of limitation of the patient's life in the long-term period of injury;
- PET (positron emission tomography). The method allows, based on the determination of the level of energy metabolism (by glucose consumption and the state of blood flow), to determine the functional changes in the brain tissue, the localization and degree of its damage. In the late period of TBI, it is more sensitive than CT in determining damage to the cortex, and especially subcortical gray matter, reveals damage to the basal nuclei of the cerebellum. PET is indicated to optimize treatment tactics in cases where clinical symptoms do not fit into the volume of brain damage according to CT or MRI data (Rudas M.S. et al., 1996);
- X-ray of the bones of the skull - detection of fractures of the bones of the skull, determination of a bone defect, its location and size, intracranial foreign bodies;
- EEG - is used in the remote period of injury in determining the localization of brain damage, in particular mesodiencephalic structures, the trunk, objectifying the epileptic nature of seizures, in order to judge the dynamics of the process;
- REG - allows you to clarify the presence and severity of angiodistonic disorders in the long-term period of TBI with autonomic dystonia, arterial hypertension;
- immunological study is used to judge the pathogenesis of the consequences of TBI, in particular cerebral arachnoiditis, to identify an immunodeficiency state;
- ophthalmological and otolaryngological examination;
- somatic and endocrinological examination (detection of neurosomatic and neuroendocrine pathology);
- experimental psychological research (in the long-term period to objectify the nature and degree of mental disorders, in particular a cognitive defect).
Differential Diagnosis
It is carried out mainly in the late period of TBI and in the absence or incomplete anamnesis, indicating the possibility of injury, due to the need to: 1) clarify the cause of epileptic seizures, narcolepsy and other paroxysmal conditions; 2) determination of the etiology of cerebral arachnoiditis, purulent meningitis; 3) diagnosis of subdural hematoma (mainly in elderly patients burdened with vascular pathology; 4) detection of dementia; 5) in some other situations.
Course and forecast
For a number of reasons, it is extremely difficult to predict the course of a traumatic disease in the acute and intermediate periods of TBI. The most difficult is the prognosis of long-term outcomes of trauma, the degree of disability and the level of social and labor readaptation of the victims. Some predictive points:
1. The severity of the injury. At the stage of long-term consequences, the clinical manifestations of mild and moderate closed TBI converge, mainly due to lesions predominantly of the limbic-reticular structures of the brain, while in severe trauma, cerebral focal lesions are significantly more common (Shogam I.I., 1989; Mikhailenko A.A. et al. ., 1993). The development of indirect consequences of closed TBI (arachnoiditis, vascular complications) is possible not only after severe, but also after mild trauma. At the same time, decompensation of post-traumatic disorders in the late period of trauma is more often observed in people who have suffered severe brain damage (Burtsev E.M., Bobrov A.S., 1986). Cognitive defect and behavioral disorders after minor trauma in most cases regress within 3 months.
2. Age of the victim at the time of injury. For example, in severe TBI, there is a dependence of a decrease in good recovery of functions from 44% in children and 39% in young people to 20% in the elderly and the elderly (Konovalov A. N. et al., 1994).
3. Topic of the lesion and the nature of the clinical syndrome (relatively best forecast with cerebral-focal syndrome, especially in persons with open TBI, than with general cerebral disorders).
4 Of undoubted importance is the usefulness of the terms and volume of treatment of victims in the acute and intermediate periods of injury. Unrecognized in early period mild TBI and associated violation of the medical and protective regimen is one of the main causes of the relapsing, and often progressive course of a traumatic disease.
5. Social factors: education, professional skills, working conditions, life, etc.
In general, with mild TBI, the prognosis for life, survival, social status, and recovery is usually favorable. In the case of moderate injury, it is often possible to achieve full recovery labor and social activity of patients, however, the consequences described above are also possible, limiting the life of patients to one degree or another. In severe TBI, mortality reaches 30-50%. Almost half of the survivors have significant disability, social insufficiency, and severe disability.
Practical recovery is observed in approximately 30% of those who have had a closed TBI. The rest meet various options the course of a traumatic disease:
1. Regredient with ongoing stabilization of clinical symptoms and maximum rehabilitation of the patient. It is observed, as a rule, in children, young and middle-aged people, in the elderly and old people, it is rare.
2. Remitting with periods of decompensation of the direct consequences of trauma and remissions. Causes: repeated injury, intoxication, infection, contraindicated conditions labor. There is no direct relationship between the nature, severity of the injury and the time of decompensation and progression.
3. Progredient with an increase in the severity of neurological symptoms, mental disorders, the appearance and development of vascular pathology (arterial hypertension, atherosclerosis). The latter can develop against the background of complete but unstable compensation at various times after an injury or at pre-retirement age after a long period of stable compensation for post-traumatic disorders. Vascular manifestations of the disease in 40% of elderly patients significantly exacerbate other consequences of TBI.
Principles of treatment in acute and intermediate periods of TBI
1- Stages and continuity of treatment:
a) at the pre-hospital stage (at the scene) - elimination of life-threatening complications (asphyxia, bleeding, shock, convulsive syndrome);
b) mandatory inpatient treatment, taking into account the nature and severity of TBI. Most appropriate in the neurosurgical department (if necessary - resuscitation, intensive observation, surgical intervention); possibly in the neurological department (minor injury); in a trauma hospital (combined injury in case of mild or moderate TBI).
2. Compliance with the terms of stay in the hospital, bed rest and optimal therapy depending on the form (severity), nature of TBI (open, closed, combined, combined, secondary, repeated, etc.).
a) concussion. Bed rest for 3-5 days, hospital stay for 7-10 days, sometimes up to 2 weeks, taking into account dynamic observation for the sick. Drug therapy - analgesics, sedatives, vegetotropic, dehydrating drugs;
b) mild to moderate brain contusion. Bed rest from 7 days (mild injury) to 2 weeks (moderate injury). Inpatient treatment up to 3-4 weeks. Directions of drug therapy: improvement of microcirculation and rheological properties blood, decrease in the degree of hypoxia (rheopolyglucin, cavinton, trental, solcoseryl, glucose-potassium-and: "sulin mixture), dehydration, antihistamines, antibiotics that penetrate the blood-brain barrier, and other means, taking into account the peculiarities clinical picture;
c) severe contusion and acute traumatic compression of the brain. Inpatient treatment usually more than a month (sometimes
2-3 months) taking into account the severity of the condition, complications, applied surgical treatment. Directions of drug therapy: the fight against cerebral hypoxia, DIC syndrome, neurovegetative blockade, correction of intracranial hypertension. Indications for surgical intervention: acute traumatic compression (hematomas, hygromas, crush areas, severe dislocation of the brain), depressed fractures of the cranial vault and
others;
d) open head injury, in particular, a fracture of the base of the skull, comminuted and gunshot wounds. The duration of inpatient treatment, taking into account the type and severity of the injury, the nature of complications (intracranial hemorrhages, meningitis, meningoencephalitis, etc.). The main ones are antibacterial and surgery. The volume and tactics of the latter depend on the characteristics of the injury.
3. Taking into account the features of treatment depending on the age of the victim, aggravating somatic pathology ( hypertonic disease, diabetes mellitus, chronic pneumonia, etc.) - For elderly patients, it is necessary: ​​a lower dosage of drugs, caution with dehydration, active use antiplatelet agents, alertness to concomitant cerebrovascular pathology, the possibility of subdural hematoma formation.

4. Special therapy for TBI complications - epileptic seizures, vestibulopathy, vegetative dysfunction, purulent meningitis (with open trauma, in particular, a fracture of the skull base, liquorrhea), pneumonia, etc. 5. From modern means- highly effective Neurostim

Medical and social expertise. Criteria for VUT

1. In acute and intermediate periods of closed TBI:
a) with a concussion of the brain VN-1-1.5 months, in some cases (ongoing bad feeling, unfavorable working conditions) up to 2-3 months;
b) with mild brain injury VN - 1.5-2 months;
c) with a bruise of an average degree of VN - 2.5-4 months, the terms depend on the nearest labor forecast. In the case of ongoing regression of symptoms, it is possible to continue treatment by decision of the CEC up to 6 months or more. In case of signs of persistent disability, it is advisable to refer to the BMSE 2-3 months after the injury;
d) with a severe bruise, the labor prognosis for a long time is unfavorable, the clinical is doubtful. Therefore, VN, as a rule, should not last more than 3-4 months.
2. In the acute and intermediate periods of open TBI, the timing of VN is different, depending on the volume of surgical intervention, the severity and nature of purulent complications. It is possible to extend the treatment on sick leave for more than 4 months with continued restoration of functions (taking into account the clinical and labor prognosis).
3. In the long-term period of TBI, patients are temporarily unable to work due to decompensation during a traumatic disease, revealed complications (chronic subdural hematoma, purulent meningitis with liquorrhea, epileptic seizures, cerebral arachnoiditis, vascular pathology and etc.). Usually, a hospital examination is necessary, treatment, the terms of which are very individual, are determined by the characteristics of complications, the severity of decompensation. After a major convulsive seizure, a severe hypertensive crisis, patients are temporarily unable to work for 2-3 days. VN is also determined in the case of plasty of a skull defect, reconstructive, bypass operations.
The main causes of disability in the long-term period of TBI
Diversity is taken into account, a different combination clinical syndromes, which most often have a complex effect on the state of life and the ability to work of patients.
1. Syndrome of vegetative dystonia. Vital activity is limited by both permanent disorders and crisis states. They also determine the labor opportunities of patients.
2. Psychopathological disorders. Asthenic, astheno-hypochondriac syndromes are manifested by a decrease in activity, inability for prolonged intellectual and physical stress, a predominance of a depressive mood background, and psychopathic-like syndromes are manifested by significant emotional instability, a tendency to affective outbursts, and torpidity in achieving the goal. Possible pathological development of personality. For asthenoorganic syndrome, a cognitive defect is typical: memory and attention decrease, the assimilation of a new one becomes difficult, and the volume of perception decreases. Life restrictions are manifested (depending on the severity and clinical features of the syndrome) in violation of social adaptation, in particular situational behavior at work, in family relationships; inappropriate behavior in crisis situations (illness, accident), unwillingness to return to work after an injury), lack of interest in social and personal events. The ability to learn (acquisition of a new profession) decreases, long-term mental and physical stress becomes impossible. This leads to a deterioration in the quality of life, may be the cause of a persistent decrease in working capacity, the need for restrictions in labor activity on the recommendation of the CEC, and with pronounced changes in the psyche and the definition of group II disability.
dementia traumatic genesis in connection with a persistent and pronounced decrease in memory, intelligence, disorientation in place, time leads to the impossibility of self-service.
3. Often progressive cochleovestibular disorders, accompanied by vestibular crises, cause a decrease in endurance to the effects of a number of factors in everyday life and at work: a sharp change in the position of the head, torso, lifting to a height, driving a vehicle, fixing the gaze on continuously moving objects. The ability to move is limited. Significant hearing impairment causes a decrease in the ability to communicate. This explains the limitations of life in everyday life, contraindicated types and working conditions. The latter are very individual, since they take into account the severity of cochleovestibular disorders and the peculiarities of the profession: slight hearing loss is allowed (hearing is necessary for contact with people in the process of work), hearing loss and aggravation of vestibulopathy are possible when exposed to atmospheric factors, excessive noise, vibration, etc. Therefore, they are not available professions in traffic service various kinds transport associated with staying at a height, underground, near moving mechanisms (in case of severe vestibular dysfunction), etc.
4. Violations of liquorodynamics can lead to a significant limitation of life and the impossibility of work, requiring significant or moderate, but constant physical stress, occurring in adverse meteorological conditions, under the influence of mental factors.
5. Epileptic seizures undoubtedly affect life activity, can lead to limitation or disability of patients in the long-term period of TBI. This takes into account the possibility of remission and transformation of seizures, their appearance under the influence of various unfavorable actors, a combination with mental disorders.
6. The narcoleptic syndrome, taking into account the imperativeness of falling asleep attacks, the possibility of cataplectic episodes, limits the ability to live and work due to the periodic violation of the patient's control over his behavior, the danger of adverse influences on him or others
^CM7. Neuroendocrine-metabolic dysfunction and neurotrophic disorders of hypothalamic origin. The degree and nature of their impact on life depends on the specific syndrome. his curability. This also determines the labor opportunities of the patient.
8. Cerebral-focal syndromes affect life and work capacity, depending on their nature, severity, ability to compensate.
9. With indirect consequences of TBI (symptomatic arterial hypertension, early atherosclerosis, other somatic complications, cerebral arachnoiditis), the degree and nature of disability depend not only on their clinical features, but also on combination with other (direct) consequences of the injury.
10. With an open TBI, the judgment about the limitation of the patient's life and work capacity, along with the above reasons, depends on additional factors: pressure, insolation, etc.;
b) the consequences of purulent complications (meningoencephalitis, etc.), as well as their danger in the presence of liquorrhea.
Examples of the formulation of the diagnosis in the remote period of injury
- long-term effects of closed TBI with moderate vestibulopathy and asthenic syndrome. State of sustainable compensation;
- long-term consequences of closed TBI (severe brain contusion) with moderately severe right-sided hemiparesis, elements of motor aphasia, rare secondary generalized tonic-clonic seizures. Unstable compensation;
- long-term consequences of repeated closed TBI with post-traumatic arterial hypertension (moderately expressed), bilateral sensorineural hearing loss with a significant
hearing loss, psychopathic syndrome. Relapsing course with frequent exacerbations;
- long-term consequences of a shrapnel penetrating wound of the right parietal region with a skull defect 3x4 cm, small metal fragments in the brain substance, mild left-sided hemiparesis, astheno-organic syndrome. The state of stable compensation.

Contraindicated types and working conditions

1. General: significant physical and mental stress, pronounced fluctuations in atmospheric pressure, exposure to toxic substances, etc.

2. Individual: depending on the underlying syndrome or a combination of several syndromes that determine the nature and degree of limitation of the patient's life.

Able-bodied patients

1. Persons who have had a mild, less often moderate closed TBI, who have practically recovered, who have fully compensated for the defect that existed in the acute period, without social insufficiency.

2. Patients with good compensation of impaired functions in the absence of contraindicated factors in the work in the specialty or with mild impairments, if rational employment is possible with restrictions on the recommendations of the CEC.

3. Patients after cranioplasty, without foreign bodies in the cranial cavity, other significant consequences of trauma and rationally employed (more often a year after surgery).

Indications for referral to BMSE

1. Unfavorable clinical and labor prognosis due to severe functional impairment and significant limitation of life despite the treatment and rehabilitation measures taken.

2. Relapsing or progressive course of a traumatic disease (late complications, vascular diseases, cerebral arachnoiditis, etc.).

3. The inability to return to work in the main specialty, a significant loss of earnings, the presence of contraindicated factors in work that cannot be eliminated by the conclusion of the CEC.

List of minimum examinations for passing the ITU

1. Results of lumbar puncture.
2. Craniogram, if necessary, an aiming picture.
3. Echo-EG, EEG, REG (according to indications).
4. CT and (or) MRI.
5. Data of ophthalmological and otorhinolaryngological examination.
6. Physician examination data; endocrinologist.

7. Experimental psychological research.

8. General clinical blood and urine tests.

Disability Criteria

Some general points:
1. During the examination in the first 6-12 months. after TBI, the main role is played by the severity of the trauma, dysfunctions caused by focal organic pathology of the brain.
2. In the long term, severe disability in 60% of cases is caused by the consequences of a relatively mild injury.
3. Indirect consequences of a closed head injury, the progressive course of a traumatic disease can be the basis for the primary determination of disability many years after the injury.
4. Possible positive dynamics of disability, return to work due to stabilization, decrease in the severity of neurological deficit, frequency of paroxysmal conditions, successful reconstructive operations(regarding the defect of the skull, liquorrhea).
5. When determining disability, the age factor matters: in the elderly and senile age, focal symptoms are more pronounced and worse regress, vascular and somatic pathology, the intermediate and remote periods of injury are lengthened, the degree of decrepitude increases.
I group: persistent pronounced dysfunctions or a combination of them, leading to a pronounced limitation of life (according to the criteria for impaired ability to move independently, orientation, self-care of the third degree).
II group: pronounced functional impairment due to neurological or mental deficiency, leading to a significant limitation of life (according to the criteria for limiting the ability to work of the third, second degree, self-service, orientation, control over one's behavior of the second degree). The cause of disability may also be a complex neurological syndromes of varying severity, and with a combined injury - a concomitant pathology musculoskeletal system, internal organs. Wherein
certain types labor may be available under specially created conditions.
III group: moderate disability (according to the criteria for impaired ability to work, movement, orientation of the first degree). This takes into account social factors: age, education, opportunities for retraining and retraining, etc.
In patients with persistent traumatic brain injuries, manifested by pronounced motor disorders, aphasia, progressive hydrocephalus, dementia, with an extensive bone defect or a foreign body in the brain substance, with the ineffectiveness of rehabilitation measures, the disability group is determined indefinitely after 5 years of observation.
The causes of disability may be different depending on the circumstances of the injury: 1) general illness; 2) an injury received during the period military service. Documentation of the injury is required. However, in the absence of military medical documents, the causal relationship of the consequences of injury, shell shock, mutilation is established by the VVK on the basis of other military documents (characteristics, award list, etc.), if they contain indications of injury, contusion, mutilation. The reason for the disability “due to military service”, but not related to “performance of military service duties” is established without military medical documents if the injury occurred during military service or no later than 3 months after dismissal from the army; 3) labor injury (in accordance with the "Guidelines for determining the causes of disability"). In this case, the BMSE is entrusted with the duty of determining the degree of loss of professional ability to work (“Regulations ...” dated April 23, 1994, No. 392); 4) disability since childhood.
The grounds for recognizing a child as disabled (more often for a period of 6 months to 2 years) are pronounced motor, mental, and speech disorders after TBI.
Disability prevention
1. Primary prevention: prevention of situations that contribute to injuries in general and TBI in particular.
2. Secondary prevention: a) compliance with the terms of bed rest, hospital stay, the optimal amount of treatment and rehabilitation measures, including surgical intervention in acute and intermediate periods of injury;
b) dispensary observation for victims after discharge from the hospital: those who have suffered a serious injury should be observed
2 times a month for the first 2 months after discharge, then at least
3-4 times a year; after a mild and moderate injury, the frequency of examination is 1 time per month for 3 months after discharge, then 1 time in 3 months; c) adherence to the terms of VN (taking into account the severity of head injury, the effectiveness of treatment, profession and working conditions, pain
leg); d) prolongation of VN for post-treatment of patients with a relatively favorable clinical and labor prognosis, the creation of facilitated working conditions for a certain time according to the conclusion of the CEC of a medical institution; e) early plasty of a significant skull defect with a homograft, autoplasty.
3. Tertiary prevention: a) prevention of complications in people with the consequences of open TBI: timely surgery in case of basal liquorrhea; optimal therapy for patients with vascular complications and cerebral arachnoiditis with closed TBI; b) rational employment of disabled people
Group III, exclusion of the impact of adverse factors in everyday life, at work; c) reasonable and timely determination of disability, taking into account the degree and nature of disability; d) implementation of other measures of social protection.
Rehabilitation
Basic principles (Ugryumov V. M. et al., 1979; Arbatskaya Yu. D., 1981): 1) the complexity of treatment and rehabilitation measures; 2) stages and continuity of treatment; 3) directed impact on the personality of the patient, taking into account premorbid features. The basis for the rehabilitation of a patient with the consequences of TBI should be individual program, compiled taking into account the rehabilitation potential, including the whole range of medical and social measures and providing for the achievement of the maximum level of rehabilitation - full, partial or domestic.
1. Medical rehabilitation. Rehabilitation treatment in the intermediate and late periods of injury: a) in the neurological department, rehabilitation hospital or center, rehabilitation department of the polyclinic, at home, taking into account the nature of the post-traumatic defect; b) in a neurosurgical hospital: plasty of a bone defect in the skull, other reconstructive operations.
2. Vocational rehabilitation. Taking into account the age of the patient, the features of functional impairment, a new specialty is trained, retraining is carried out, followed by rational employment. Specific labor recommendations should take into account the clinical features and course of a traumatic disease, contraindicated types and working conditions, social and professional factors, and the patient's personal inclinations.

3. Social rehabilitation provides for the training of a disabled person in self-service, depending on the nature of the defect, psychotherapy. Often, psychological support is also needed for family members of the patient. An important measure of social assistance is the provision of a patient with a motor defect after TBI with special manually operated vehicles (in accordance with the "List of medical indications ..." and taking into account contraindications), as well as technical means for rehabilitation (hearing aid, special simulators, etc.).

In 80% of patients who survived to admission to emergency room, light damage. Moderate and severe together account for 10% of the total number of injuries. Traumatic brain injury survivors often remain with varying degrees of disability, which occurs in approximately 10% of survivors of mild traumatic brain injury, 50-67% of those after moderate trauma, and more than 95% of those after severe closed traumatic brain injury.
The most widely used means to assess the outcome of traumatic brain injury is the Glasgow Coma Scale.

Outcome can be determined many different ways . While survival means a good outcome for the healthcare provider, significant comorbid disability can make the same outcome bad for the family or patient. In discussing outcome prediction, it is important to clarify what is meant by outcome and good outcome.

Relatively and concept disability. The same disruption can be a disaster for one patient and a minor hindrance for another. An example would be the impact of losing the ability to calculate, which would incapacitate an accountant but would only be a minor hindrance to a gardener.

However, epidemiological and financial data reflect only part of the story. Psychological and social consequences head injuries are huge. Many patients experience significant depression from loss of independence, social isolation, declining earnings that are often permanent and significant (if not absolute), and loss of economic status. Family members often experience rage and depression at the upheaval in their lives caused by trauma.

Predicting the outcome of traumatic brain injury

Gradually, different models appeared forecast. Different outcome measures have different weights and different priorities, depending on the population they apply to. A symptom that does not promise prospects in old age may have much less ominous consequences for a younger patient. As a result, generalization of data from a specific population and a prediction model for generalized groups of patients are often inappropriate. Applying predictive models to everyday practice should be done with caution.

Although very good and very bad outcomes usually can be predicted with a high degree of certainty soon after the injury, the prognosis for intermediate categories is much more difficult. Studies have shown that even with careful consideration of known indicators, physicians tend to overestimate the likelihood of a poor outcome and underestimate the likelihood of a good outcome in the early treatment of patients with head injuries. In one study, the accuracy of doctors' predictions was only 56%.

This phenomenon " false pessimism» acquires special meaning in relation to a publication showing that healthcare providers are adjusting their treatment based on these predictions, expanding the use of effective methods those who are potentially promising in terms of outcome, and reducing their use in those who, in their opinion, are unpromising. Therefore, caution should be exercised in offering or withholding predictions in patients with brain damage at early stages treatment.

Elena, good afternoon!
When resolving a dispute, you can file a claim for compensation for non-pecuniary damage. If there are concerns, then the protocols will not take measurements of a fraudulent doctor, etc. Accordingly, if you wrote a well-known petition for criminal liability under Art. 25 Code of Criminal Procedure of the Russian Federation. Argue the decision in the end, but it concerns that it is forbidden to conclude an employment contract with the company, did not conclude and receive evidence that you sell it to our property, therefore, to commit in your case, you need to better conclude that within 3 years from the date filing a lawsuit against him to file an eviction lawsuit may be included in the register of this security.
There are the following violations of joint ownership. If necessary, attach to the case to the investigator who has relatives at the time of the formation of his ownership of such ownership.
If you acquire personal space, then the gift can be cancelled. Regarding the fact that the mother did not include in the inheritance or understood, then the sale of the share was tracing the property to her if your parents buy housing. Do not let smayar from you personally receive a deduction - an exhaustive answer.
In particular, you have the right to resolve the problem in court in court, the possibility of judicially demanding the payment of rent to you and on what conclusion you will have to do this. Therefore, if you have already left for all your shares of the seller (or some cars, etc.) and it will become a reason, since you will continue your long-term training with involvement in an organization consisting of one of the categories and forcibly fully forwarded to him the sent part will notify the supervisor, there must be indicated to obtain refugee status.
Article 12
1. The length of service, along with the periods of work and (or) other activities, which are provided for in Article 10 of this Federal Law, shall include:
1) the period of military service, as well as other service equivalent to it, provided for by the Law of the Russian Federation "On pensions for persons who have completed military service, service in the internal affairs bodies, the State Fire Service, bodies for controlling the circulation of narcotic drugs and psychotropic substances, institutions and bodies of the penitentiary system, and their families.
Thus, based on the above, there are legal grounds claim that:
1) if a child was born from persons who are married to each other, as well as within three hundred days from the moment of dissolution of marriage, its recognition as invalid or from the moment of death of the spouse of the mother of the child, the spouse is recognized as the father of the child ( former spouse) mother, unless proven otherwise (Article 52 of this Code). The paternity of the spouse of the mother of the child is certified by a record of their marriage.
If the loan does not recognize them as a disadvantage for the reasons established by paragraph 1 of Article 1153 of the Civil Code of the Russian Federation, then in accordance with Art. 200 of the Civil Code of the Russian Federation to general obligations, a minimum compensation may be established jointly with other persons, including those imposed in the terms stipulated by the contract for the inadequate quality of the consumer society.
Article 318 material liability occurs in case of violation of the contract of retail sale and purchase, to return the money or exchange the goods of inadequate quality of joint and several obligations, if it proves that it would have largely lost what it was entitled to count on when concluding the contract, on the basis of which the parties proceeded when concluding the contract, is the basis for its change or termination, unless otherwise provided by the contract or follows from its essence.
A change in circumstances is recognized as significant when they have changed so much that, if the parties could reasonably foresee this, the contract would not have been concluded by them at all or would have been concluded on significantly different terms.
2. If the parties have not reached an agreement on bringing the contract in line with the significantly changed circumstances or on its termination, the contract may be terminated, and on the grounds provided for in paragraph 4 of this article, amended by the court at the request of the interested party, if the following conditions are simultaneously present:
1) at the time of the conclusion of the contract, the parties proceeded from the fact that such a change in circumstances would not occur,
2) the change in circumstances is caused by reasons that the interested party is liable for the damage caused to the plaintiff in exceptional cases when the termination of the contract is contrary to public interests or will entail damage to the parties that significantly exceeds the costs necessary to fulfill the contract on the conditions changed by the court.
2. In the event that the contract of sale refused to fulfill the contract of sale and demand the return of the amount paid for the goods. At the same time, the consumer is also entitled to demand full compensation for losses caused to him as a result of violation of the deadline for the transfer of prepaid goods established by the contract of sale.
3. In case of violation of the deadline for the transfer of the prepaid goods to the consumer, established by the purchase and sale agreement, the seller shall pay him for each day of delay a penalty (penalty) in the amount of half a percent of the amount of the prepayment for the goods.
The penalty (penalty) is collected from the day when, under the contract of sale, the transfer of goods to the consumer should have been carried out, until the day the goods were transferred to the consumer or until the day the consumer's demand for the return of the amount previously paid by him is satisfied.
The amount of the penalty (penalty) collected by the consumer cannot exceed the amount of the advance payment for the goods.
4. The requirements of the consumer for the return of the amount paid for the goods and for the full compensation for losses are subject to satisfaction by the seller within ten days from the date of presentation of the relevant requirement.
5. The requirements of the consumer, established by paragraph 2 of this article, shall not be satisfied if the seller proves that the violation of the terms for the transfer of the prepaid goods to the consumer occurred due to force majeure or through the fault of the consumer.
Sincerely.
Ermilov Anatoly Vitalievich, lawyer.

The first group of disability is established for patients who have experienced a complete permanent or long-term disability, in need of constant outside care, assistance or supervision. The first group of disability should be established by patients with long-term consequences brain injury with severe hemiparesis in combination with aphasia or a patient with total aphasia, traumatic epilepsy with profound personality changes, twilight states of consciousness and frequent major seizures. In some cases, disabled people of the first group can be adapted to certain types of labor activity in specially organized individual conditions: work at home, in special workshops, etc.

The second group of disability is established for patients with traumatic brain lesions who have experienced a complete or prolonged disability, but who do not need constant outside care, help or supervision, for example, patients with the consequences of brain injuries with severe diencephalic disorders or severe traumatic parkinsonism, significant hypertension with frequent liquorodynamic crises, etc. Some disabled people of the second group can be adapted to work in specially created conditions (work at home), perform occasional advisory work in institutions, etc.

The criteria for establishing the third group of disability are:

1. The need to transfer for health reasons to a job of lower qualification. For example, the third disability group should be established for patients with the consequences of brain contusion, with rare elileptiform seizures, who have the specialty of a driver, tractor driver, machine operator, etc., since this work is contraindicated for them, and transfer to another job, even with the use of professional skills, is usually associated with a decrease in qualifications: the transfer of the driver by the garage dispatcher, the tractor driver - to minor locksmith work, etc.

2. The need for health reasons to significantly change the working conditions in their profession, leading to a significant reduction in the volume of production activities and often to a decrease in qualifications. For example, the transfer of a patient from the work of the chief engineer of a plant to the work of an engineer of a small department due to a pronounced astheno-explosive syndrome after a penetrating wound of the skull; transfer of a patient from the work of a prosecutor, a lawyer to the work of a legal adviser in a small institution due to persistent residual effects of brain contusion with mild hemiparesis and significant asthenization of the personality.

3. A significant limitation of the possibilities of employment due to pronounced functional impairments in persons of low qualification or who have not previously worked. For example, the third group of disability is established for a patient with the consequences of a skull injury with vestibular disorders and moderately severe intracranial hypertension, who previously worked in hard physical work (loader, rigger, ordinary collective farmer, etc.) and has no education. The possibilities of a labor device for such a patient are very limited. He can only perform light ancillary work or simple types of work. manual labor in the artel of the disabled.

4. The third group of disability is also established if it is possible to continue the previously performed work for patients with the consequences of a craniocerebral injury without pronounced functional impairment, but in the presence of an extensive skull defect or intracranial foreign bodies. In these cases, the disability group is established according to the criterion of "pronounced defect" indefinitely.

When establishing a disability group, VTEK must also determine its cause. With traumatic brain injuries, the cause may be different depending on the circumstances of the injury: disability due to injury, contusion at the front, due to work injury, from common causes(domestic injury, injury not related to an accident at work, etc.). The cause of disability determines the amount of pension provision, as well as the right to receive a number of privileges provided by law for various contingents of disabled people. In case of traumatic lesions of the brain, if the patient is recognized as disabled, the causes, disability due to injury or contusion at the front, or in connection with the performance of military service duties, are established if he has military medical documents in his hands (certificate of illness, certificate in the form No. 16, an extract from the medical history from the hospital, a certificate from the military medical archive, etc.), which indicate that “the wound, contusion were received in connection with the stay at the front”, “in connection with the performance of military service duties”. The cause of disability "due to military service", but not related "to the performance of military service duties", is established without military medical documents, if the brain injury that led to disability occurred during military service or no later than 3 months after dismissal from military service. With regard to former servicemen dismissed from the army not due to illness, but due to other circumstances (by order, in connection with demobilization, etc.), the cause of disability is “due to a shell shock or wound at the front”, or “in connection with the performance of duties of a military service "can be established at any time after demobilization, if the former soldier became disabled as a result of a brain injury received at the front or while performing military service duties and this is confirmed by documents.

In cases where the patient has military medical documents in his hands and he is demobilized due to illness, but the VTEK does not agree with the decision on the cause of disability indicated in the military medical documents, the VTEK must apply to the CVVK with a request to review the cause of disability and continue to act in accordance with the decision of the military medical commission.

The cause of disability from a work injury is established not only when the brain injury that led to disability was received during work, but also on the way to and from work, at lunchtime, when carrying out instructions from party and trade union organizations, on a business trip (on a business trip). office hours). The cause of disability from a work injury can also be established when a traumatic brain injury in itself does not lead to a decrease in working capacity, but is a moment that provokes the development or progression of a disease, for example, early cerebral atherosclerosis,

Traumatic brain injury, like any traumatic process, is acute (it is not for nothing that the acute period of TBI is distinguished). Given the functional importance of brain structures in the life of the body, it should be considered that in the acute period of TBI, all victims are temporarily unable to work. However, the timing of VN will be different in patients even with the same clinical form of traumatic injury. Labor and clinical forecasts largely depend on the correct conduct of EVN. When evaluating the clinical and labor prognosis in the acute period of TBI, one should take into account the factors that affect the timing of LT, namely:

the severity of the trauma in the acute period of the traumatic process (there is a direct relationship between clinical form TBI, its severity and duration of VN);

the age of the victim at the time of injury (in children and persons young age the compensatory abilities of the body are higher than in the elderly, burdened with concomitant pathology);

the topic of the lesion and the nature of the clinical (clinical) syndrome (syndromes);

social factors (especially the nature and conditions of the work performed).

Of particular importance in this category of patients is complete treatment with observance of necessary terms of VN and the medical and protective mode; early discharge to work will lead to decompensation of post-traumatic disorders and the transition of the regenerative type of flow into a progressive or remitting one. Therefore, in case of EVN in patients who have undergone TBI, it is necessary to take into account both medical and social factors, as well as the approximate terms of VN recommended by the Ministry of Health and the FSS of the Russian Federation.

In the acute period of TBI, all victims need inpatient treatment, since only stationary conditions it is possible to provide a full-fledged medical and protective regimen (ie, a state of physical and, most importantly, mental peace).

When determining the terms of inpatient treatment, one should take into account the terms recommended in the relevant chapters of this Guide, since they were developed taking into account many years of observations and scientific research conducted under the guidance of leading specialists from the main medical institution in our country dealing with the problem of neurotraumatism - the Institute of Neurosurgery named after N.N. .Burdenko.

At the same time, regional standards for the provision of medical care in a hospital, therefore, with concussions of the brain, the recommended period of inpatient treatment is from 3 to 8 days, which corresponds to the approved approximate terms of VN (including bed rest for 1 to 3 days). Depending on the clinical course, the period of temporary disability ranges from 3 to 4 weeks, which also corresponds to the approved indicative terms of VN.

The attention of doctors should be drawn to the fact that the duration of the acute period of TBI (up to 2 weeks) and the duration of LN do not coincide, which is not an accident. This is a well-thought-out expert tactic that allows you to assess the compensatory abilities of the body and include in the total duration of the LL not only the duration of the acute period, but also part of the intermediate one.

A concussion is a clinical form related to mild TBI, not accompanied by significant functional disorders, characterized by the reversibility of functional disorders. Therefore, the prognosis for concussion, both clinical and labor, is favorable, and patients return to work, in which they were employed before the injury. In some cases, certain categories of workers may be recommended to restrict work according to the conclusion of the CEC of a health care facility (temporarily or permanently), if there are contraindicated factors in the work performed (exposure to harmful production factors, significant physical and neuropsychic stress, work in night time, additional and overtime work, etc.). These patients can be recommended to work on an individual schedule.

However, sometimes there is an unfavorable course of the post-traumatic process, accompanied by the transition of reversible functional disorders to persistent, irreversible ones, which will be clinically manifested by an increase in cerebral symptoms, primarily by deepening psychopathological disorders, cephalalgia. This will lead to the need for additional consultations with specialists (psychiatrist, psychologist, psychotherapist), an increase in the volume of drug therapy and the adoption additional measures to correct impaired functions. Therefore, in this category of patients, the duration of VN will be longer. This clinical form, with apparent expert simplicity (the prognosis is clear -

.■ ■".-;",■. - ■

favorable) actually presents certain difficulties: with a premature discharge to work, the post-traumatic process may progress, but if the patient is “overexposed” at home, continuing, sometimes without sufficient reason, to prolong the LN, rental attitudes begin to form in him, which makes it difficult to be discharged to work. work. Therefore, the clinician must be able to draw a clear line between the clinical recovery that has already begun and the current post-traumatic process that is still ongoing in order to timely discharge the patient to work.

In the approved indicative terms, the remaining clinical forms of TBI are not presented. Therefore, we offer only the terms of inpatient treatment recommended by specialists of the N.N. Burdenko Institute of Neurosurgery for the indicated clinical forms of TBI:

mild brain contusion - 10-14 days;

brain contusion of moderate severity - 14-21 days.

The basic principles of the expert approach mentioned above should be observed when determining the total duration of VL in these clinical forms of TBI for further rehabilitation measures, including referral to the ITU.

The total duration of VN should cover not only the acute period of TBI, but also a part of the intermediate period for assessing the adaptive and compensatory capabilities of the organism. When determining the duration of LN, we recommend that the attending physicians use another expert principle, LN should be extended as long as the regression of pathological symptoms continues, which is a favorable prognostic sign. At the end of the recovery process, the issue of further management of the patient will be determined by the remaining clinical symptoms that have not regressed. In severe TBI (severe brain contusion, diffuse axonal damage, brain compression), the clinical prognosis is either doubtful (unclear) or unfavorable, which leads to unfavorable labor prognosis. Despite this, patients should receive the full scope of medical care, incl. in a hospital, the length of stay in which will depend on clinical symptoms and its regression. Severe forms of traumatic brain injury in the absence of regression of the main clinical

Some syndromes require timely referral of patients to the ITU at an earlier date (due to the obvious unfavorable prognosis), not exceeding 4 months of LT, and sometimes even earlier. However, in some cases with severe forms of TBI, as a rule, in young people with good compensatory capabilities, the regression of the main syndromes can continue even after 4 months, which is a good prognostic sign and, despite the severity of the injury, in these patients, LN can be extended until completion. recovery process.

In acute and intermediate periods, TBI in some cases is complicated by: hematomas of various localization, skull fractures, bone defects, foreign bodies in the brain substance, purulent complications that necessitate additional treatment, incl. operational, affect the prognosis and increase the timing of VN. Subsequently, with the formed type of course of the consequences of traumatic brain injury (remitting or progressive), LN can occur either during an exacerbation (decompensation) or when the rate of progression changes. The term of VN in these cases will be determined by the time of compensation. As a rule, this period ranges from 2 to 4 weeks, depending on the severity of clinical symptoms, the speed of their regression and the adequacy of the prescribed treatment. The most common type of course of the consequences of traumatic injury is relapsing, which is due to many factors, incl. non-compliance with the medical and protective regimen, unfavorable working conditions, intoxications, incl. alcoholic. Under unfavorable conditions, the remitting type of flow can turn into a progressive one, which in the end always leads to permanent disability (disability).

33.2.2. Medical and social expertise in traumatic brain injury

Traumatic brain injury is one of the leading causes leading not only to temporary, but also to permanent disability, especially in young people who are the most socially active. Thus, annually from the total number of people recognized as disabled for the first time due to injuries of all localizations, more than 35% are

Clinical Guide to Traumatic Brain Injury

disabled people with consequences of TBI. At the same time, in most cases, people of the most able-bodied age - up to 45 years old - become disabled. The severity of the consequences of craniocerebral traumatism is noteworthy: a large proportion is made up of disabled people of groups II and I, i.e. disabled and in need of constant care. According to various authors, in the structure of disability, their number reaches 63% (according to E.M. Boeva), 40-60 % - according to the St. Petersburg Institute for the Improvement of Doctors-Experts, 80 % - according to the Moscow Neurosurgical Bureau ITU. A higher percentage of disability of groups 1 and 2 in the ITU neurosurgical bureau is due to the fact that more severe victims are examined there.

In accordance with the current regulatory documents, the decision on the establishment of a disability group is entrusted to the Bureau of Medical and Social Expertise (BMSE). Due to the special importance of the problem of traumatic brain injury and the large number of victims who need highly qualified and high-tech assistance, on the basis of the leading scientific institution of our country, the N.N. Burdenko Institute of Neurosurgery, about 40 years ago, on the initiative of the director of the institute A. I. Arutyunov, the first and only neurosurgical VTEK in the country was created, which later became the neurosurgical BMSE.

This was an act of humane treatment of seriously injured patients who needed long-term treatment, the result of which was not always predictable, and their relatives. This saved them from the agonizing procedure for patients required documents and re-examination.

Every year, about 250 primary and 400 recurrent patients with TBI pass through the neurosurgical BMS (among 2000-2100 examined, i.e. every third patient with the consequences of TBI).

Patients who, despite the full range of medical and rehabilitation and social and labor measures, have an unfavorable clinical and labor prognosis, pronounced functional disorders persist, have a relapsing or progressive course of the disease, leading to permanent disability and working capacity, i.e. to disability.

Medico-social expertise of patients with traumatic brain injury is based on a comprehensive analysis of medical, social and professional factors. When assessing medical factors, the nature (open, closed), severity, clinical form of the injury, all complications and consequences, the effectiveness of the treatment, and the severity of dysfunction are taken into account. When assessing social factors, family status, living conditions, financial situation, conditions for social adaptation, the ability to perform household activities, the ability to independent existence, independent living are taken into account.

The analysis of occupational data is carried out taking into account general and vocational education, main profession, qualifications, professional route, total work experience, compliance with the psychophysiological requirements of the main profession, the patient's health status; the profession in which the disabled person works at the time of the examination, the conditions and organization of his work, the rationality of employment, the labor orientation of the examined person, the preservation of his professional knowledge and skills, the ability to acquire knowledge, master skills.

Based on the analysis of these data, a judgment is made about the preservation or violation of the professional and labor status due to limited ability to work and / or ability to learn, differentiated by three degrees of severity, as well as disability. Long-term observations of patients who have undergone TBI indicate an extreme polymorphism of clinical manifestations in its long-term period, which are characterized by a diverse dysfunction of the nervous system, other organs and physiological systems of the body and affect the state of working capacity. Patients are disabled by disorders of the mental functions of the emotional sphere, speech disorders, epileptic seizures, disorders of static-dynamic function (paresis, paralysis of the limbs, cerebellar-kestibular disorders), liquorodynamic disorders manifested by cephalgic syndrome, vegetative-vascular disorders, etc.

Restriction of self-service of the first degree is observed with moderate motor disorders (moderate paresis, moderate hemiparesis,

Medical examination for traumatic brain injury

moderate vestibular-cerebellar disorders), in which self-service is possible with the help of assistive devices. The second degree of self-service restriction is due to severe motor disorders: severe hemiparesis, severe vestibular-cerebellar disorders with a pronounced persistent psycho-organic syndrome, in which self-service is possible with the use of aids and / or with the partial assistance of other persons. Inability to self-service and complete dependence on other persons (third degree of limitation) is observed in patients with significantly pronounced motor disorders (gross, significantly pronounced hemiparesis, paraparesis), vestibular-cerebellar disorders, with the inability to perform coordinated movements, walking, psychoorganic dementia syndrome.

The first degree of restriction of movement is characterized by difficulty in independent movement due to moderate movement disorders. The second degree of restriction of movement is observed in patients with severe motor disorders, when movement is possible with the use of assistive devices and / or partial assistance of other persons. The third degree of restriction of movement occurs in patients with significantly pronounced motor disorders and is characterized by an inability to move independently and complete dependence on other persons.

The first degree of restriction of labor activity corresponds to the state of health of the patient with such consequences of a traumatic brain injury that prevent him from performing work in his main profession, and the recommended employment is associated with a decrease or loss of qualification or a decrease in the volume of production activity. The second degree of restriction of labor activity corresponds to the state of health of the patient with such consequences of TBI, in which labor activity is possible only in specially created conditions using auxiliary means or a specially equipped workplace and / or with the help of other persons (with pronounced motor, vegetative-vascular, psychopathological violations, etc.) or not possible at all. Under specially created conditions is understood the organization of work, in which the victim is set a reduced working day, individual production standards, additional

breaks in work, appropriate sanitary and hygienic conditions are created, the workplace is equipped with special technical equipment, systematic medical supervision and other measures are carried out.

33.2.2.1. Criteria for determining disability groups for traumatic brain injury

The disability group is established taking into account the degree of limitation of certain categories of life activity or their combination.

33.2.2.1.1. Criteria for determining the first group of disability

The first group of disability is established in cases where, due to persistent, significantly pronounced disorders caused by the consequences of TBI, the patient cannot serve himself and needs constant outside help, care and supervision. At the same time, functional disorders lead to a pronounced limitation of one of the following categories of life activity or their combination: limitation of the ability to self-service of the third degree (paralysis, significantly pronounced paresis, hemiparesis, paraparesis, tetraparesis; pronounced atactic disorders, generalized persistent hyperkinesis, significantly pronounced subcortical amiostatic cue syndrome, dementia, etc.).

Limitation of the ability to move is caused by the same syndromes as the ability to self-care of the third degree. Restriction of the ability to orientate the third degree is caused by dementia, blindness, a concentric decrease in visual fields of 5-10 °, etc.

Restriction of the ability to communicate of the third degree occurs in patients with significantly pronounced speech disorders (total aphasia, psychoorganic syndrome with the transition to dementia).

Restriction of the ability to control one's behavior of the third degree is observed in patients with significant impairment of higher cortical functions, leading to dementia.

33.2.2.1.2. Criteria for determining the second group of disability

The second group of disability is determined by persons who have social insufficiency requiring social protection or assistance,

Clinical Guide to Traumatic Brain Injury

caused by the consequences of TBI and leading to a pronounced limitation of one of the following categories of life activity or their combination:

limitation of the ability to self-service of the second degree;

limitation of the ability to move the second degree;

limitation of the ability to learn the third, second degree (inability to learn, the ability to learn only in special educational institutions or special programs at home);

limitation of the ability to work of the third, second degree (inability to work, the ability to perform work in specially created conditions using auxiliary means and (or) a specially equipped workplace, with the help of other persons) in patients with pronounced motor, speech, visual, vegetative-vascular, liquorodynamic, vestibular-cerebellar, psychopathological and other disorders;

limitation of the ability to orientate the second degree.

Restriction of the ability to communicate of the second degree occurs in patients with severe speech disorders (motor aphasia, dysarthria), severe hearing loss in both ears, severe psychoorganic syndrome with a tendency to affective reactions.

Restriction of control over one's behavior of the second degree is due to severe cognitive disorders, frequent paroxysmal conditions and generalized epileptic seizures.

33.2.2.1.3. Definition criteria

third group of disability

The third disability group is defined as persons who have social insufficiency requiring social protection or assistance due to a health disorder with a persistent minor or moderately pronounced disorder of body functions due to the consequences of TBI, leading to a mild or moderately severe limitation of one of the following categories or their combination:

Restriction of the ability to self-care and movement of the first degree;

Teaching ability of the first degree (ability to study in educational institutions of a general type, subject to a special regime of the educational process and (or) using auxiliary means, with the help of other persons (except for teaching staff));

Restriction of the ability to work of the first degree occurs in patients with minor moderate consequences of TBI, with various functional disorders ( paroxysmal form vegetative-vascular dystonia, with rare or moderate frequency, mild or moderate severity, as well as rare severe crises; with vestibular or liquorodynamic disorders, disorders with rare or average frequency of paroxysmal conditions, etc.), if they lead to a decrease in qualification, a decrease in volume production activities or inability to perform work in their profession.

It should be noted that in this category of disability, not only moderately pronounced functional disorders are taken into account, but also minor ones, if they interfere with the performance of work in the main profession. For all other disabilities, at least the presence of moderate functional disorders is required to determine the disability group.

Restriction of the ability to orientate the first degree is observed with moderately severe visual and auditory disorders due to TBI, for the correction of which auxiliary means and special correction are used.

Restriction of first degree communication ability and first degree learning ability may be the basis for establishing the third group mainly in combination with the restriction of one or more other categories of life activity.

According to the last, seventh, criterion for limiting the ability to control one's behavior of the first degree, the establishment of a disability group is not provided.

When conducting MSE of persons who have had TBI, it should be taken into account that the deficiency of brain functions associated with organic focal pathology is much less pronounced in the long-term period compared to the acute one. If in the first year after the injury a direct relationship is revealed between the clinical form of the injury, its severity and the time of onset of disability

Medical examination for traumatic brain injury

(as a rule, persons who have suffered moderate and severe traumatic brain injury become disabled: moderate and severe brain contusion, diffuse axonal damage, brain compression), then in the long-term period there is no such dependence, and often a relatively mild injury (concussion of the head brain injury, mild contusion) is accompanied by severe impairment of body functions, remitting or steadily progressive type of course, leading to disability in the long term.

At the same time, when conducting MSE in the long-term period of TBI, the nature of the course of the post-traumatic process should be taken into account. If patients, despite the ongoing treatment, have a relapsing type of course with frequent long-term decompensations or a progressive course with severe functional impairment, patients need to be referred to the MSE.

33.2.2.2. Cause of disability

During the examination at the ITU Bureau, simultaneously with the determination of the disability group, the issue of its cause is resolved.

The causes of disability in people with the consequences of TBI can be the following:

general illness;

since childhood;

work injury;

when fulfilling the duty of a citizen of the Russian Federation;

due to military trauma;

injury (contusion, mutilation) received during military service;

a wound (concussion, mutilation) received in battles while defending the USSR at the front;

general illness (labor injury) received in the area of ​​military operations;

injury (wound, contusion, mutilation) received in the performance of military service duties;

wound (contusion, mutilation) received at the front;

injury (contusion, mutilation) received in the performance of international duty;

wound (contusion, mutilation) received during other military operations;

disabled child.

We have listed the most common causes of disability in the practice of the ITU Bureau, although their list is much longer.

33.2.2.3. Peculiarities

medical and social expertise in children with consequences of traumatic brain injury

Taking into account the peculiarities of the course of traumatic brain injury in children, a certain procedure has been developed for recognizing this category of children as disabled.

Currently, for children under 18 years of age, the concept of a “child with a disability” has been established. The following terms of disability are provided: from 6 months to 2 years, from 2 years to 5 years and for a period up to the age of 18 (“Instructive and methodological materials for establishing disability in children” of the Ministry of Health of the Russian Federation, M., 1996).

The medical indications for recognizing a child as disabled due to TBI are as follows.